By Cassie Jewell, M.Ed., LPC, LSATP
Throughout my counseling career, group therapy has been a focal part of what I do. I’ve worked mainly in residential settings where groups take place several times a day.
Initially, group counseling terrified me. (What if I can’t “control” the group? What if a member challenges me? What if I can’t think of anything to say? What if everyone gets up and leaves? – that actually happened, once – and on and on. What made group therapy especially intimidating was that if I “messed up,” an entire group of people [as opposed to one person] would witness my failure.)
I got over it, of course. Group facilitation wasn’t always comfortable and I made many (many!) mistakes, but I grew. I realized it’s okay to be both counselor and human; at times, humans say dumb stuff, hurt each other’s feelings, and don’t know the answer. By letting go of the need to be perfect, I became more effective. Group facilitation is now one of my favorite parts of the job.
This resource guide provides practical information and tools for group therapy for mental health practitioners.
Group Therapy Guidelines
Group therapy is an evidence-based treatment for substance use and mental disorders. An effective group calls for a skilled clinician to meet treatment standards. Professional associations, such as the American Group Psychotherapy Association, develop best practice guidelines based on scientific data and clinical research.
- Association for Specialists in Group Work: Best Practice Guidelines 2007 Revisions | (2008) An 8-page document
- Practice Guidelines for Group Psychotherapy | (2007) An 85-page document developed by the American Group Psychotherapy Association
SAMHSA promotes research-based protocols and has published several group therapy guides for best practice, including TIP 41: Substance Abuse Treatment: Group Therapy, Substance Abuse Treatment: Group Therapy – Quick Guide for Clinicians, and Substance Abuse Treatment: Group Therapy Inservice Training (a training manual), in addition to group workbooks/facilitator guides for anger management, stimulant use disorder, and serious mental illness.
Group Exercises for Addiction Counseling (2012) by Dr. Geri Miller
The book itself is small in size but packed with helpful information and creative ideas. As a new counselor lacking in clinical skills, I supplemented with activities to engage the clients. Group Exercises for Addiction Counseling never failed me.
250 Brief, Creative & Practical Art Therapy Techniques: A Guide for Clinicians and Clients (2019) by Susan I. Buchalter
A more recent discovery of mine. This guide provides detailed instructions accompanied by thought-provoking discussion questions for each intervention. I was impressed with both the quality and originality; an instant upgrade to “house-tree-person.”
For clinical group practice
- Corey, M. S., Corey, G., & Corey, C. (2018). Groups: Process and practice.
- Yalom, I. D., & Leszcz, M. (2015). The theory and practice of group psychotherapy.
Icebreakers & Teambuilding
You need only Google “icebreakers” and you’ll have a million to choose from. I’m not listing many, but they’re ones clients seem to enjoy the most.
Activity 1. My most highly recommended icebreaker activity involves passing out blank slips of paper to each group member and instructing them to write a “fun fact” about themselves, something no one else in the group would know. I provide them with examples (i.e. “I once had a pet lamb named Bluebell” or “I won a hotdog eating contest when I was 11 and then threw up all over the judges’ shoes”). Depending on the crowd, you may want to tell clients not to write anything they wouldn’t want their peers to know. (I adopted this guideline after a client wrote about “sharting” himself.) Once everyone has written something, have them fold their papers and place in a container of some sort (a gift box, paper bag, plastic bowl, etc.) Group members take turns passing around the container (one-at-a-time) and picking a slip to read aloud. They must then guess who wrote it. (I give three guesses; after that, I turn it over to the group.)
Activity 2: A similar but more structured activity is to write out questions ahead of time and have clients take turns drawing and answering the questions. Questions can be silly, thought-provoking, or intending to illicit a strong emotional response (depending on the audience and goals for the group).
Activity 3: “People Search” involves a list of traits, feats, talents, or experiences. Each client receives the list and is given x amount of time to find someone in the group who is a match; that individual will then sign off. The first person to have their list completely signed sits down; they win. I typically let clients continue to collect signatures until two additional people sit down. (Prizes optional, but always appreciated.) During the debriefing, it’s fun to learn more (and thereby increase understanding and compassion).
Activity 4: “First Impressions” works best with group members who don’t know each other well. It’s important for group members to know each other’s names (or wear name tags). Each group member has a sheet of paper with various “impressions” (i.e. judgments/stereotypes). For example, items on the list might be “Looks like an addict” and “Looks intelligent.” Clients write other group members’ names for each impression. In addition to enhancing a sense of community, this activity provides an avenue for discussing harmful stereotypes and stigma.
Activity 5: Affirmations groups can be powerful, generating unity and kindness. The effect seems to be more pronounced in gender-specific groups. There are a variety of ways to facilitate an affirmations group, ranging from each person providing an affirmation to the client on their right to individuals sharing a self-affirmation with the group to creating a self-affirmation painting. Another idea is to give each client a sheet of paper. (Consider using quality, brightly-colored paper/posterboard and providing markers, gel pens, etc.) Clients write their name on it and then all the papers are passed around so each group member has the opportunity to write on everyone else’s sheet. Once their original paper is returned to them, they can read and share with the group. This can lead to a powerful discussion about image, reputation, feeling fake, etc. (Plus, clients get to keep the papers!)
Activity 6: “Most Likely to Relapse/Least Likely to Relapse” works best with a well-formed group and may require extra staff support. It’s good for larger groups and can be highly effective in a therapeutic community. Clients receive blank pieces of paper and are tasked to write the names of who they think is most likely and least likely to relapse. After writing their own name on the sheet, they turn it in to staff (effectively allowing staff to maintain a safe and productive environment). Staff then read each sheet aloud (without naming who wrote it). If they choose, clients can share what they wrote and provide additional feedback. (Most do.) Clients selected as “most likely” (in either category) have the opportunity to process with other group members and staff.
Access group therapy worksheets and handouts here.
Links to Additional Group Activities
- Addictions: 36 Addiction Recovery Group Activities | (2018)
- Expressive Therapist: Group Activities | 75 group activities for children, teenagers, and adults in a mental health setting
- Group Therapy Activities for Adults from Love To Know
- Group Therapy Activities for Substance Abuse & Relapse Prevention from Oxford Treatment Center (2020)
- Music Therapy Activity Ideas | Blog posts include printable lyrics and worksheets
- Two Dreams: 60 Substance Abuse Group Therapy Activities | (2015)
- Two Dreams: 60 MORE Substance Abuse Group Therapy Activities | (2016)
Psychoeducation & Process Groups
In need of fresh material? It can be easy to fall into a rut, especially if you’re burnout or working with a particularly challenging group. The following three PDF downloads are lists of ideas for group topics. I also included two links to sites with helpful suggestions.
- Positive Psychology: Your Ultimate Group Therapy Guide (+ Activities & Topic Ideas) | (2020)
- THERAPlatform: Psychoeducational Group Topics | (2019) Includes group categories for different populations
As a group facilitator, consider incorporating some sort of experiential activity, quiz, handout, game, etc. into every session. For example, start with a check-in, review a handout, facilitate a discussion, take a 5-minute bathroom break, facilitate a role-play, and then close the group by summarizing and providing clients with the opportunity to share what they learned. If that’s not feasible, provide coffee or snacks; sitting for 45 minutes is difficult for some, and 90 minutes can be unbearable.
Another idea is to have a “fun” or “free” group in the curriculum. Ideas include going bowling, having a potluck, Starbucks run, game group (i.e. Catchphrase, Pictionary, etc.), escape room, nature walk, etc.
Dealing With Challenges
Clients are not always willing therapy participants; some are court-ordered to attend or there to have privileges restored. Some attendees may be there “voluntarily,” but only to save their marriage or keep a job, not believing they need help. In residential treatment, clients attend mandatory groups as part of the daily schedule — participate or you’re out.
Even when attendance is truly voluntary, a group member may be in a bad space. Maybe they’re stressed about the rent or just got into a fight with their significant other. Or what if the AC is broken and the group room is 80 degrees? What if a client has unpleasant body odor or bad breath or an annoying cough?
Multiple factors combine and it’s suddenly a sh**show. (I’ll never forget the client who climbed onto a chair to “rally the troops” against my tyranny.) Anticipating challenges is the first step to effectively preventing and managing them.
Click here for an excellent article from Counseling Today that addresses the concept of client resistance.
Tips for dealing with challenges
- If possible, co-facilitate. One clinician leads while the other observes. The observer remains attuned to the general “tone” of the group, i.e. facial expressions, body language, etc.
- Review the expectations at the beginning of every group. Ask clients to share the guidelines with each other (instead of you telling them). This promotes a collaborative spirit.
- After guidelines are reviewed, explain that while interrupting is discouraged, there may be times when you interject to maintain overall wellness and safety. (Knowing this, a client is less likely to get angry or feel disrespected when/if it happens.)
- If you must interrupt, apologize, and explain the rationale.
- Avoid power struggles at all costs, especially when a client challenges the benefits of treatment. (The unhealthier group members will quickly side with a challenger, leading to a complaint session.) Challenging the efficacy of treatment (or you as a clinician) is often a defense mechanism. Sometimes, the best response is simply “okay,” or none at all… and keep moving. You can also acknowledge the client’s perspective and ask to meet with them after group (and then get back on topic). If the group is relatively healthy, you may want to illicit feedback from other group members.
- If a client becomes angry or tearful, give them time to vent for a moment or two (don’t “Band-Aid”); they may be able to self-regulate. (If they do self-regulate, share your observations and offer praise.)
- If a client’s anger escalates to a disruptive level, ask them to take a break. At this point, their behavior is potentially triggering to other group members. Don’t raise your voice or ask them to calm down. Direct them step out and return when they’re ready. You may have to repeat yourself several times, but remain firm and calm, and they will eventually listen.
- If a client is disrespectful (cursing at you or another client, name-calling, insulting, etc.) while escalated, let them know it’s not okay, but don’t attempt to provide feedback. (A simple, “Hey, that’s not okay,” will suffice.) Bring it up with the client later when they’re able to process.
- Once the client who has been disrespectful leaves the room, acknowledge what happened and let the group know you will follow up with the client. If another client wants to talk about it, ask them to share only how it made them feel, but stress that it’s not okay to talk about an absent group member. (“How would you feel if we talked about you when you weren’t here?”) Strongly suggest that they wait until the person returns (and is open) to have a group discussion.
- After a major blow-up (and once everyone is calm), it can be beneficial for the group to process it with the person who escalated. Group members can empathize/relate, share their observations and/or how it made them feel, and offer feedback.
- If other disruptive behaviors occur in group (side conversations, snoring, etc.) address them in the moment (without shaming, of course). Point out the behavior and explain how it’s disruptive to the group. Refer back to the group guidelines. Ask group members to comment as well. If you let a behavior persist, hoping it will eventually stop, you’re sending the message that it’s okay, not only to the person who is disruptive, but to the entire group. This impacts the integrity of the group and opens things up for additional disruptive behaviors.
- For clients who monopolize, who are constantly joking, or who attempt to intentionally distract by changing the topic, point out your observations and encourage group members to give feedback.
- If, on the other hand, clients seem disengaged or unmotivated, seek out their feedback, privately or in the group, whichever is clinically appropriate.
- If there’s a general level of disengagement, bring it up in the group. Remain objective and state your observations.
- Anticipate that at times, people may not have much to say. (And while yes, there’s always something to talk about, that doesn’t mean someone is ready to or has the emotional energy to.) Maybe they’re distracted or tired or feeling “talked out.” It’s good to have backup plans: watch a psychoeducational film, take a walk in the park, listen to meditations or music, provide worksheets, education reading material, or coloring sheets.
Always keep in mind a client’s stage of change, their internal experiences (i.e. hearing voices, social anxiety, paranoia, physical pain, etc.), external circumstances (i.e. recent medication change, loss of housing, conflict with roommates, etc.), and history of trauma. What looks like resistance may be something else entirely.
Professional Group Therapy Associations
- The Australian Association of Group Psychotherapists
- American Group Psychotherapy Association
- The American Society of Group Psychotherapy and Psychodrama
- Associations for Specialists in Group Work
- The Canadian Group Psychotherapy Association
- Eastern Group Psychotherapy Association
- Georgian Group Psychotherapy Association
- Group Psychotherapy Association of Los Angeles
- Houston Group Psychotherapy Society
- Illinois Group Psychotherapy Society
- International Association for Group Psychotherapy and Group Processes
- International Association for Social Work with Groups
- Mid-Atlantic Group Psychotherapy Society
- Northeastern Society for Group Psychotherapy
- Northern California Group Psychotherapy Society
- The Philadelphia Area Group Psychotherapy Society
- Puget Sound Group Psychotherapy Network
- Society of Group Psychology and Group Psychotherapy
- Westchester Group Psychotherapy Society
- Adverse Outcomes in Group Psychotherapy | Roback, H. B. (2000). Adverse outcomes in group psychotherapy: Risk factors, prevention, and research directions. The Journal of Psychotherapy Practice and Research, 9(3), 113–122.
- Complexities with Group Therapy Facilitation in Substance Use Disorder Specialty Treatment Settings | Wendt, D. C., & Gone, J. P. (2018). Complexities with group therapy facilitation in substance use disorder specialty treatment settings. Journal of Substance Abuse Treatment, 88, 9–17.
- Differences that Make a Difference | Change-Caffaro, S., & Caffaro, J. (2018). Differences that make a difference: Diversity and the process group leader. International Journal of Group Psychotherapy, 00: 1-15.
- Group Interventions | Ezhumalai, S., Muralidhar, D., Dhanasekarapandian, R., & Nikketha, B. S. (2018). Group interventions. Indian Journal of Psychiatry, 60(Suppl 4), S514–S521.
- Group Therapy for Substance Use Disorders | Wendt, D. C., & Gone, J. P. (2017). Group therapy for substance use disorders: A survey of clinician practices. Journal of Groups in Addiction & Recovery, 12(4), 243–259.
- Modeling Cohesion Change in Group Psychotherapy | Tucker, J. R. (2016). Modeling cohesion change in group psychotherapy: The influence of group leader behaviors and client characteristics. Graduate Theses and Dissertations, 15175.
- Self-Efficacy and Substance Use Outcomes for Women in Single-Gender Versus Mixed-Gender Group Treatment | Cummings, A. M., Gallop, R. J., & Greenfield, S. F. (2010). Self-efficacy and substance use outcomes for women in single gender versus mixed-gender group treatment. Journal of Groups in Addiction & Recovery, 5(1), 4–16.
- American Psychological Association: Keys to Great Group Therapy | (2019) An article with expert advice from experienced clinicians
- Evidence on the Effectiveness of Group Psychotherapy | A short article from American Group Psychotherapy Association
- GoodTherapy: Group Therapy | (2019) A short but informative article on the role of group therapy in treatment and types of groups
- An Interview with Irvin Yalom from The Free Library by Farlex | (2007) A interview with one of the leading individuals in the realm of group therapy
- MindTools: Forming, Storming, Norming, and Performing | A short article that discusses the stages of team formation. The theory is often applicable in group therapy.
- Psychotherapy Guide: Group Therapy vs. Individual Therapy | (Source: American Addiction Centers) (2019) This article discusses the advantages and disadvantages of group therapy as treatment for substance use disorders
- Roles People Play in Groups | (Source: Stanford) Identifies and discusses task, maintenance, and hindering roles in groups
- All About Group and Team Facilitation | (Source: The Free Management Library) This site provides free resources for managers, entrepreneurs, and leaders; much of the content on facilitation and teams is applicable to group facilitation
- The Center for Group Studies
- Group Dynamics | A blog all about group dynamics
- My Group Guide | Provides materials to use in groups (a few freebies, but most of the handouts/worksheets are only accessible via paid subscription). Resourceful blog for group work and more.
- Resources in Group Psychotherapy